Alyn Morice University of Hull HYMS

AHM 2011

Alyn MoriceUniversity of HullHYMS

COPDDisease notDisorder?

What is COPD?

Asthma (eosinophilic bronchitis)

Emphysema Chronic Bronchitis(neutrophilic bronchitis)

2010

Page 1 of 673!

COPD Treatment Pathway

Establish diagnosis of COPD in at risk population with history, examination and spirometry (FEV1/FEV ratio <70%) Establish severity of disease by FEV1 as % predicted

Management of RISK FACTORS plus EDUCATION plus IMMUNISATION

Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised)

SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues

PHARMACOLOGICAL TREATMENT

Review at each step after one month before escalating treatment

THEOPHYLLINE

MUCOLYTICS

prn short acting β2 agonist

Tiotropium + short acting β2 agonist

SHORTNESS OF BREATH

Consider Palliative Care Referral in End Stage Disease

Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol

Tiotropium + combination LABA and inhaled corticosteroid

(Seretide 500 accuhaler or Symbicort 200/6)

COUGH AND SPUTUM

Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss)

Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)

Telemonitoring in COPD – the evidence base• Numerous pilot projects with accompanying evaluation

reports;– Often exceptionally good results (e.g. COPD telehealth in SE

Essex – 75% reduction in A&E attendances; 83% reduction in hospital admissions)

– Often methodologically limited (e.g. before-and-after studies; small sample sizes)

• Systematic reviews demonstrate that high-quality evidence base is still immature;– Bolton (2010): studies included were positive but of a low-

quality– Polisena (2010): Telehealth interventions improved QoL and

reduced hospitalisations

Best health, best health care, a health service fit for the East Riding

Evaluation…• Evaluation of first 3 months deployment (24 patients) showed:

- Patient satisfaction generally very good

- 68% reduction in n/e admission costs

- net saving per month

- achievement of £0.5m QIPP saving feasible

• Evaluation by Hull University – full year evaluation due Dec 11

Best health, best health care, a health service fit for the East Riding

The East Riding Model

• Risk stratification identifies patient

• MDT agrees intervention

Protocols for response in place:GP, NCT , specialist services,

secondary care

GP’s/NCT

1. Referral for telehealth

intervention

2. Patient registered & unit installed

Patient at risk of deterioration

2. Alerts

3. Triage

4. Response

1. Monitoring

IDENTIFY

REFERMONITOR

RESPOND

Telephone patient Visit - within identified timescale

Emergency Response

Step up / Step down Community Beds

Telemonitoring in COPD – How can it work?

Telemonitoring in COPD – suggested mechanisms of action• It has been suggested that telemonitoring can

support COPD patients by;– Providing reassurance and support

Telemonitoring in COPD – suggested mechanisms of action• It has been suggested that telemonitoring can

support COPD patients by;– Increasing knowledge of disease process and

enhancing self-care– Providing reassurance and support

Best health, best health care, a health service fit for the East Riding

Roger• 64 year old with chronic, severe COPD• Housebound and anxious• Frequently uses standby medication• Frequent hospital admissions – anxiety rather

than healthcare need• Distrustful of clinicians due to previous experience

After telehealth:

• Telephone contact to reassure• Patient keeps diary of results and more knowledgeable about condition eg, trends/patterns• More proactive about asking for help• Reduced hospital admissions

Telehealth then...

14

Telemonitoring in COPD – suggested mechanisms of action• It has been suggested that telemonitoring can support COPD

patients by;– Enabling earlier detection of exacerbation (e.g. due to

reporting of worsening symptoms)– Increasing knowledge of disease process and enhancing

self-care– Providing reassurance and support

The impact of frequent COPD exacerbations - more frequent attacks increase mortality

Soler-Cataluna JJ, et al. Thorax 2005;60:925–931

Group A: no exacerbationsGroup B: 1–2 exacerbationsGroup C: ≥3 exacerbations

n=304

Time (months)

p<0.0001

p<0.0002A

B

C

p=0.069

0 10 20 30 40 50 60

1.0

0.8

0.6

0.4

0.2

0

Surv

ival

pro

babi

lity

COPD patients with productive cough• More likely to have exacerbations

Seemungal TA et al. Am J Respir Crit Care Med 98

• More rapid decline in lung functionVestbo J 1996, Kanner RA et al. Am J Respir Crit Care Med 01

• More likely to die earlyPrescott E et al. Eur Respir J 1995

% o

f pat

ient

s

On Later in the In the In the At night Waking morning afternoon evening

31.0

24.0 22.519.5

10.6

Breathlessness (n=1,769)

28.825.9 25.4 25.5

16.7

Chest tightness (n=690)

40

30

20

10

0

Timing of symptoms: when was each symptom the most troublesome?

19

% o

f pat

ient

s

On Later in the In the In the At night Waking morning afternoon evening

40

30

20

10

0

% o

f pat

ient

s

On Later in the In the In the At night Waking morning afternoon evening

48.9

22.3

14.918.7 17.3

Cough (n=1,433)50

40

30

20

10

0

% o

f pat

ient

s

On Later in the In the In the At night Waking morning afternoon evening

56.7

26.2

16.3 16.611.8

Phlegm (n=1,551)60

50

40

30

20

10

0

Partridge et al. ERS Vienna 2009

HULL AIRWAYS REFLUX QUESTIONNAIREName:D.O.B:____________________________ UN: _________________DATE OF TEST:Please circle the most appropriate response for each question

Within the last MONTH, how did the following problems affect you? 0 = no problem and 5 = severe/frequent problem

Hoarseness or a problem with your voice 0 1 2 3 4 5

Clearing your throat 0 1 2 3 4 5

Excess mucus in the throat, or drip down the back of your nose

0 1 2 3 4 5

Retching or vomiting when you cough 0 1 2 3 4 5

Cough on first lying down or bending over 0 1 2 3 4 5

Chest tightness or wheeze when coughing 0 1 2 3 4 5

Heartburn, indigestion, stomach acid coming up (or do you take medications for this, if yes score 5)

0 1 2 3 4 5

A tickle in your throat, or a lump in your throat 0 1 2 3 4 5

Cough with eating (during or straight after meals) 0 1 2 3 4 5

Cough with certain foods 0 1 2 3 4 5

Cough when you get out of bed in the morning 0 1 2 3 4 5

Cough brought on by singing or speaking (for example, on the telephone)

0 1 2 3 4 5

Coughing during the day rather than night 0 1 2 3 4 5

A strange taste in your mouth 0 1 2 3 4 5TOTAL SCORE_____________ /70

www.issc.info

History of Cough Recording

Woolf & Rosenberg,Thorax 1964:19;125

History of Cough Recording

Woolf & Rosenberg,Thorax 1964:19;125

unprocessed file

processed file

Waveforms showing acoustic events – Pre and post filtering

Cough counting in exacerbations of COPD

• Day 1 546 coughs• Day 5 162 coughs

0

10

20

3040

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Time hours

cough/hour

Future of telemonitoring in COPD

25